When the drugs don’t work

Global push to address resistance gathers pace

World leaders came together this week to agree on a global response to the escalating problem of Antimicrobial Drug Resistance (AMR), but will new measures actually reach the developing world where they are most needed?

Common and life-threatening infections like pneumonia, as well as HIV, tuberculosis, and malaria are increasingly becoming untreatable, as bacteria, viruses, and parasites develop resistance against medicines that used to be effective.

At a meeting on AMR at the UN’s General Assembly on Wednesday, 193 member states agreed to take action. It was only the fourth time in the UN’s history that such a high-level gathering had been called to address a health-related crisis.

If the global commitment leads to new approaches, it would be particularly important for poor countries, where a high burden of infectious diseases, lack of access to vaccines and life-saving drugs, and poor health infrastructure have contributed to spiralling levels of drug resistance.

Waking up to a new crisis

World Health Organization Director General Margaret Chan has warned that all antibiotics could eventually be rendered useless due to AMR, which has developed partly because of inappropriate antibiotic use in people, farm animals, and agriculture. In a post-antibiotic world, common ailments such as a strep throat or an infected wound could prove fatal. A recent report commissioned by the UK government estimates that by the year 2050, 10 million people could die annually as a result of AMR. Currently, an estimated 700,000 die each year from bacterial infections that are multi-drug-resistant.

The problem has already gone beyond the domain of health ministers. Economists and heads of state are now focused on the issue. Citing the UK government-commissioned report, Keiji Fukuda, the WHO’s special representative for antimicrobial resistance, said global economic losses from AMR could be as high as $100 trillion by 2050.

The topic was front and centre at the UN this week. Besides the high-level meeting, there were a number of side events on the issue. At a press briefing, Fukuda said the pledge by heads of state to take action was indicative of the seriousness of the crisis.

“It’s of the order of HIV or climate change,” he said. “Besides not being able to treat infected people, the whole basis of modern medicine could become shaky.” Fukuda raised the specter of life-saving operations becoming too dangerous to perform because of the risks of untreatable post-operative infections. “Around the world we’re seeing these problems. We’re seeing on a daily basis, infections that are untreatable and resistant to medications.”

Hitting the poor hardest

Although most of the research on AMR comes from wealthier countries, resistance to HIV and TB drugs, and now malaria, is having the biggest impact in poorer countries where these diseases are most prevalent. The UK study estimates that 90 percent of deaths resulting from AMR will be in developing countries, and that one quarter of all deaths will be related to TB.

Contributing to the problem is the ready availability of antibiotics over the counter, and even online, in many developing countries.

In a statement, Médecins Sans Frontiéres said it was seeing drug-resistant infections everywhere it works, “from the war-wounded in Jordan, to newborns in Pakistan and burn patients in Haiti, to people with multi-drug-resistant tuberculosis in South Africa”. Some of these can only be treated with the last line of antibiotics, it said.

Keith Klugman, pneumonia director at the Bill and Melinda Gates Foundation, said AMR was also a growing concern in poor urban environments, where sewage containing resistant bacteria contaminates water and then spreads throughout an area. “We are seeing this in places in India and Africa,” he said.

But Klugman told IRIN that deaths resulting from lack of antibiotics are still more common in Africa than those caused by antibiotics: “What is desperately needed is more drugs in rural areas as well as more vaccines to protect children and adults from diseases, which limits the need for antibiotics in the first place.”

New drugs needed

The core objectives of a Global Action Plan on AMR launched by the WHO in 2015 are to: cut down antibiotic use in humans and animals; reduce infections with prevention measures like vaccines and better sanitation and hygiene; improve research and surveillance of the problem; educate the public, medical staff, and farmers on the proper use of antibiotics; and invest in new medicines and diagnostic tools.

The final objective addresses the fact that pharmaceutical companies have not brought a new antibiotic to the market for the past 30 years, largely because they have not proved profitable. The UK study shows that venture capitalists invested less than five percent in antimicrobial development from 2003 to 2013. When new second- and third-line antibiotic drugs do come on the market, they tend to be unaffordable in many countries. This week’s global declaration aims to create an enabling environment for the pharmaceutical sector to develop new drugs, with a call for governments to provide public funding for research and development.

“We need a system of access to medicine where, when new antibiotics are developed, they must be sold at the cheapest price so everyone can afford them,” commented Martin Khor, executive director of the South Centre, an intergovernmental organisation that supports cooperation between developing countries.

Khor added that a number of preconditions would be needed to make the public funding model a success. For example, the public sector would need to have ownership of patents for drugs developed with public money, and those rights would then need to be passed on to generic companies to make affordable versions.

Prevent the infection first?

Judit Rius Sanjuan, manager of MSF’s Access Campaign, said the declaration that emerged from Wednesday’s meeting commits governments to “groundbreaking public health safeguards” and the need for new research on AMR to be patient-driven rather than profit-driven. “If the declaration’s commitment on de-linkage [of drug research from profits] is implemented, it could be a game-changer,” she told IRIN.

She added that while talk of better “stewardship” and changing behaviours to restrict unnecessary antibiotic use was important, it was “a very Northern-driven [developed world] response”.

“There is a lack of recognition that many health systems in the [Global] South need support. They lack the diagnostic and other tools and interventions to respond to the challenge,” she said, noting that many poor countries lack the capacity even to monitor the scale of the problem.

At a presentation on AMR at the Ford Foundation in New York this week, South African Health Minister Aaron Motsoaledi criticised the high cost of new drugs to treat multi-drug-resistant tuberculosis.

Motsoaledi said fighting TB was not being sufficiently prioritised by organisations like the UN or the World Bank, despite being the world’s leading cause of death from infectious disease alongside HIV. Unless there is more focus on combatting TB, the battle against AMR will be lost, he said.

Marc Mendelson, head of infectious diseases and HIV at the University of Cape Town, argued the merits of an infection prevention approach to AMR rather than prioritising the development of new drugs. “If we had clean water, we could drop antibiotic use by half. If we had vaccinations, we wouldn’t need the antibiotics in the first place.”

(TOP PHOTO: Tun Aung Kyaw, a MDR-TB patient, has his blood pressure checked while being treated at the Wangpha TB clinic in Thailand. Sean Kimmons/IRIN)